Metabolic bone disease of prematurity screening and individualized enteral mineral supplementation in high-risk neonates: a quality improvement initiative.

OBJECTIVE: Prompted by an alarmingly low screening rate for metabolic bone disease of prematurity (MBDP), we aimed to increase MBDP screening with serum calcium, phosphorous, and alkaline phosphatase at four to six weeks of life in infants born at <1500 g and <32 gestational weeks from a baseline of 27.37% to 90% within one year. STUDY DESIGN: We used the Institute for Healthcare Improvement's Model for Improvement as a framework. A key driver diagram informed the interventions which were carried out through four Plan-Do-Study-Act cycles. RESULTS: There were 129 and 130 neonates in the pre-intervention baseline group and post-intervention MBDP bundle group, respectively. MBDP bundled primary screening rates increased from 27.37% to 95.56% (p < 0.001). Furthermore, 20% of infants had an individualized change in their enteral mineral supplementation after the initiative. CONCLUSIONS: An interdisciplinary team-based quality improvement approach was effective in altering clinical practice to improve screening and subsequent treatment for MBDP.

Effect of Health Insurance Status and Visitation Restrictions on Virtual Visitation Technology in the Neonatal Intensive Care Unit.

OBJECTIVE: This study aimed to examine the relationship between virtual technology system utilization and insurance status or type of visitation restrictions in a single-center neonatal intensive care unit. STUDY DESIGN: Prospective cohort study with separate analyses performed based on insurance status (public vs. nonpublic) and "in effect" unit visitation restrictions. The three study epochs based on patient visitation restrictions were Epoch 1 (July to October 2019) with standard visitation restrictions, Epoch 2 (November 2019 to February 2020) with respiratory syncytial virus/influenza visitation restrictions, and Epoch 3 (March to June 2020) with coronavirus disease 2019 (COVID-19) visitation restrictions, respectively. RESULTS: Families of 357 infants used web-based cameras through most of the infant's hospitalization (median: 86.05%, Q3: 97.9%) with 165,795 total camera logins, indicating consistent utilization. There was a trend for fewer logins per infant and significantly longer time to consent (p = 0.03) in the Public Insurance group. Unit visitation restrictions impacted the time to consent, the shortest being in Epoch 3 during the COVID-19 pandemic (p = 0.03). CONCLUSION: Virtual visitation technology is well embraced by neonatal instensive care unit families; however, gaps in access and use among subgroups signals a form of social inequality that needs to be explored further. KEY POINTS: · Virtual visitation technology can bridge the distance gap for families of hospitalized infants.. · Utilization of virtual technology is affected by socioeconomic factors and seasonal unit visitation restrictions.. · Factors influencing disparities in access and utilization of virtual technology need to be investigated further..

A Standardized, 3-Tiered, Seizure Burden-Based Protocol for the Treatment of Neonatal Seizures.

OBJECTIVE: To evaluate use of a standardized, 3-tiered, seizure burden-based protocol for treatment of all electroencephalography (EEG)-confirmed seizures in a level IV neonatal intensive care unit (NICU). STUDY DESIGN: All infants admitted to the NICU with EEG-confirmed seizures over a 25-month period were enrolled in the study. We compared short-term outcomes before and after implementation of a standardized, 3-tiered protocol. RESULTS: A total of 107 infants were enrolled in the study. Use of midazolam infusions was reduced by 53.7% (p = 0.02). Midazolam infusion duration increased from 4 to 7.5 days (p = 0.003); however, when excluding 3 outliers, there was no significant difference between groups (-p = 0.67). Duration of EEG monitoring decreased from 5 to 3 days (p = 0.005). Hospital length of stay was unchanged. CONCLUSION: Implementation of a standardized, 3-tiered protocol for treatment of neonatal seizures improved short-term outcomes. Although not measured directly, reductions in EEG duration and midazolam use are promising indicators of overall seizure burden. More research is needed to evaluate impact on long-term neurodevelopmental outcomes.

Tolerability and Safety of Lacosamide in Neonatal Population.

Lacosamide is a newer antiepileptic medication used in refractory neonatal seizures with limited safety and efficacy data. This case series spans 4 years and includes 38 neonates cared for in the neonatal, pediatric, and cardiovascular intensive care units, who received lacosamide for refractory seizures. Because lacosamide affects atrioventricular node function in adults, among other metrics, electrocardiogram (ECG) changes were monitored closely in these neonates. Within this cohort, 2 neonates were found to have atrial bigeminy on ECG and telemetry. Otherwise, lacosamide was generally well tolerated with sleepiness being the most common symptom noted. This case series reports data on the tolerability of lacosamide and emphasizes the importance of monitoring key cardiac intervals with ECG before and after the use of lacosamide in this population.

Neonatal Electroencephalogram Electrode-Related Pressure Injury Prevention Quality Improvement Study.

OBJECTIVE: To lengthen the days between electroencephalogram electrode-related pressure injury (EERPI) to 100 EERPI-free days in 6 months of study implementation with a goal to maintain 200 EERPI-free days thereafter (≤1 EERPI event/year). METHODS: This quality improvement study took place in a level IV neonatal ICU over three epochs spanning 2 years: epoch 1 or baseline (January-June 2019), epoch 2 or implementation of intervention (July-December 2019), and epoch 3 or sustainment (January-December 2020). A daily electroencephalogram (EEG) skin assessment tool, introduction in practice of a flexible hydrogel EEG electrode, and successive rapid-cycle staff-education sessions were key interventions of the study. RESULTS: Seventy-six infants were monitored for 214 continuous EEG (cEEG) days, of which six (13.2%) developed EERPI in epoch 1. Eighty infants were monitored for 193 cEEG days, of which two (2.5%) developed EERPI in epoch 2. One hundred thirty-nine infants were monitored for 338 cEEG days, and none developed EERPI in epoch 3. There was no statistical difference with respect to the median cEEG days among study epochs. A G-chart of EERPI-free days showed an increase in EERPI-free days from an average of 34 days in epoch 1 to 182 days in epoch 2 and 365 days (or zero harm) in epoch 3. Skin erythema from EEG electrodes was noted during the study. CONCLUSIONS: The structured study interventions eliminated EERPI events in infants monitored with cEEG. Preventive intervention at the cEEG-electrode level coupled with skin assessment successfully reduced EERPIs in neonates.

Impact of a Standardized Nutrition Bundle Including Donor Human Milk on Hospital Outcomes in Very Low Birth-Weight (VLBW) Infants in a Safety-Net Hospital.

BACKGROUND: Standardized protocols have been shown to reduce clinical practice variation and improve patient outcomes. PURPOSE: To measure the impact of a standardized nutrition bundle inclusive of donor human milk (DHM) on hospital outcomes of very low birth-weight (VLBW) infants in a safety-net hospital. METHODS: The study used the Model for Improvement methodology to drive improvement in practice. Outcome measures consisted of necrotizing enterocolitis (NEC), mortality, growth at 36 weeks' postmenstrual age and discharge, as well as volume and type of milk consumption during hospitalization. FINDINGS: NEC rate decreased from 16.67% in the control group to 6.78% in the standardized nutrition bundle group (P = .07). Similarly, there was significant reduction in mortality with the bundled intervention (15.6% in the control group vs 1.6% in the nutrition bundle group; P = .006). Time to first (15 vs 27.5 hours of life; P < .001) and full-volume enteral feeding (8.5 vs 10 days; P = .086) were reduced in the standardized nutrition bundle group compared with the control group. The human milk volume almost doubled with the intervention. IMPLICATIONS FOR PRACTICE: Our standardized nutrition bundle protocol inclusive of DHM resulted in lower NEC rates and reduced mortality. The implementation of the DHM program proved to be cost-effective and saved lives. Our findings may help guide development of a structured approach to nutrition protocols inclusive of DHM that can be adapted by other units located in safety-net hospitals. IMPLICATIONS FOR RESEARCH: Future research on ethnic and racial barriers to access and affordability of DHM is warranted and much needed.

The impact of the Baby Friendly Hospital Initiative on neonatal hypoglycemia.

OBJECTIVE: To assess Neonatal Intensive Care Unit (NICU) admissions for hypoglycemia after the introduction of the Baby Friendly Hospital Initiative (BFHI), followed by implementation of American Academy of Pediatrics recommended hypoglycemia guidelines. STUDY DESIGN: Retrospective review of NICU admissions for hypoglycemia. Eligible subjects were healthy infants >35 weeks gestation transferred to a NICU for hypoglycemia. Infants admitted with other pathologies were excluded. NICU admissions from 3 different 18-month epochs (1 = pre-BFHI; 2 = post-BFHI; 3 = post-BFHI+hypoglycemia guidelines) were compared. RESULTS: After implementation of BFHI there was a statistically significant increase in admissions for hypoglycemia (Epoch 2 = 1.23% vs Epoch 1 = 0.55%, p < 0.001). Followed by a decrease in admissions after the implementation of hypoglycemia guidelines (Epoch 2 = 1.23% vs Epoch 3 = 0.76%, p = 0.03). CONCLUSION: NICU admissions for hypoglycemia increased with the BFHI. Hypoglycemia guidelines decreased NICU admissions, but not to the pre-BFHI baseline.

Very low birth weight infant care: adherence to a new nutrition protocol improves growth outcomes and reduces infectious risk.

BACKGROUND: Very low birth weight (VLBW) infants are at risk for postnatal growth restriction due to inadequate nutrient delivery and concomitant illness. Integrated clinical pathways or protocols can improve growth outcomes by decreasing practice variability. METHODS: A comprehensive nutrition bundle comprising standardized recommendations for initiating, advancing, and fortifying enteral feedings, and timely discontinuation of central lines was implemented in July 2012. Eligible were infants with a birth weight of <1500 g and <34 weeks gestation who were born over a 1-year period pre- and post-intervention, respectively. The primary aim was to determine if the intervention improved anthropometric parameter delta z scores at 36 weeks PMA. Secondary aims included time to first and full enteral feedings, central line-days, and rates of necrotizing enterocolitis (NEC) and sepsis/sepsis-like episodes. RESULTS: A total of 299 infants were included, of which 156 received the proposed intervention (Nutrition bundle group), and 143 received non-standardized nutrition practices (Conventional group). Median delta z scores for length (-1.2 versus -1.71; p=0.01) and head circumference (-0.73 versus -1.21; p=0.03) but not weight at 36 weeks PMA (-1.42 versus -1.58; p=0.74) were significantly higher in the Nutrition bundle group as compared to the Conventional group. Fewer infants in the intervention group had severe growth restriction. Time to first feed, full feeds, and central line duration were significantly shorter in the intervention period. The incidence of NEC and sepsis/sepsis-like episodes decreased with the intervention. CONCLUSIONS: A strategy using a comprehensive nutrition bundle improved linear and head circumference growth, reduced postnatal growth restriction, and decreased comorbidities in VLBW infants.

Improved Filtering of Pulse Oximeter Monitoring Alarms in the Neonatal ICU: Bedside Significance.

BACKGROUND: The OxiMax N-600x containing SatSeconds alarm management software was designed to assist clinicians in discriminating nuisance alarms from those that are clinically relevant. Instead of sounding an alarm the moment the oxygen saturation reading violates the upper or lower limit settings, a magnitude and duration of tolerance can be set. The primary objective was to study the proportion of nuisance alarms relative to the proportion of clinically relevant alarms being filtered under 4 different SatSeconds alarm settings (ie, 10, 25, 50, and 100) in the neonatal intensive care environment. METHODS: This is an observational prospective study of 50 infants cared for in 3 large neonatal ICUs. Infants were monitored for 4 continuous h each by a study observer with the study monitor, in addition to standard multiparameter monitors. The performance of the SatSeconds alarm was compared with nursing intervention. RESULTS: The area under the receiver operating characteristic curve (95% CI) for SatSeconds alarm settings when compared with nursing intervention were as follows: 0.61 (0.57-0.66) when the SatSeconds alarm setting was off, 0.63 (0.59-0.68) for the 10 SatSeconds alarm setting, 0.64 (0.59-0.69) for the 25 SatSeconds alarm setting, 0.64 (0.59-0.69) for the 50 SatSeconds alarm setting, and 0.63 (0.58-0.68) for the 100 SatSeconds alarm setting, respectively. CONCLUSIONS: The SatSeconds feature of the OxiMax N-600x pulse oximeter reduced some nuisance alarms; however, its specificity to nurse-identified desaturation events does not significantly improve with lengthening SatSeconds alarm settings.

A pilot study of Biotene OralBalance® gel for oral care in mechanically ventilated preterm neonates.

BACKGROUND: Neonatal ventilator-associated pneumonia (VAP) is associated with increased morbidity and mortality. In adults on mechanical ventilation, timed oral care decreases the frequency of VAP, but this approach has not been studied in neonates. OBJECTIVES: To evaluate the feasibility of a randomized trial of timed oral care with Biotene OralBalance® gel and estimate the required sample size for such a trial. METHODS: Infants were eligible for enrollment if they were born before 28 weeks of gestation, and were mechanically ventilated between 7 and 10 postnatal days. Infants were randomized to receive timed oral care with Biotene OralBalance® gel or sterile water. All subjects were treated with a standard bundle of procedures to reduce the risk of VAP. RESULTS: We enrolled 41 of 46 eligible infants (89%). Compliance with timed oral care protocol was 97%. No local oral side effects of Biotene OralBalance® gel were observed. There were no significant group differences in mortality or short-term outcomes, except length of hospital stay which was significantly shorter in the Sterile water group (p = 0.02). A lower rate of VAP was found in the Biotene group, although the difference was not statistically significant (9/1000 ventilator-days versus 17/1000 ventilator-days in the Sterile water group, respectively; p = 0.16). CONCLUSIONS: The results of this pilot study support the feasibility of a randomized trial of timed oral care with Biotene OralBalance® gel for prevention of VAP in mechanically ventilated neonates.

A randomized, controlled trial comparing two different continuous positive airway pressure systems for the successful extubation of extremely low birth weight infants.

OBJECTIVE: To determine whether the use of the Infant Flow continuous positive airway pressure (IF CPAP) system reduces the rate of extubation failure among extremely low birth weight (ELBW) infants (infants with birth weight <1000 g) when compared with conventional CPAP delivered with a conventional ventilator and nasal prongs. METHODS: A prospective, unmasked, randomized, controlled clinical trial was conducted in 162 eligible intubated ELBW infants who were hospitalized in 2 intensive care nurseries in Winston-Salem, North Carolina, between July 1997 and November 2000. Successful extubation was defined as no need for reintubation for any reason for at least 7 days after the first extubation attempt. RESULTS: The individual extubation success rates were 61.9% (52 of 84) in the conventional CPAP group and 61.5% (48 of 78) in the IF CPAP group. There were no significant differences in the extubation success rate in any birth weight subset between the 2 cohorts. The most common cause of extubation failure was apnea/bradycardia. Infants who were randomized to IF CPAP had fewer days on supplemental O(2) and shorter hospital stays. CONCLUSIONS: Extubation failure is a common problem, occurring in nearly 40% of ELBW infants who require mechanical ventilation. IF CPAP was as effective but no more effective than conventional CPAP in preventing extubation failure among ELBW infants. New strategies are needed to identify predictors of extubation success and to treat apnea/bradycardia, the most common cause of extubation failure, thereby reducing the likelihood of prolonged intubation in this high-risk cohort of premature infants.